2015 2016 membership application
TRANSCRIPT
Membership Application2015 - 2016
Name: Credentials: Employer: Position: Employer Address: City: State: Zip: Work Phone: Work E-mail: Home Address: City: State: Zip: Home Phone: Home E-mail: Preferred E-mail Address: Home Work
Are you an ANPD member? Yes NoList other Professional Organization Memberships:
Referred to CANPD by: Annual Dues*: $30.00I opt out of the scholarship donation. Optional Scholarship Donation: $ Total: $ Method of Payment: Cash Check #____ Make checks payable to: CANPD
*Dues are comprised of $20 membership and $10 Carmen Hovanec Scholarship.Mail completed form and payment to:
CANPDPO Box 525
Western Springs, Il 60558
__________________________________________________________Receipt
Chicago Association for Nursing Professional DevelopmentAnnual dues $30 Check # CashOptional Scholarship Donation
(tax deductable)$ Check # Cash
Member’s name:Treasurer or Designate: Date: